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Dressings and Products in Pediatric Wound Care

Alice King,1,2 Judith J. Stellar,3 Anne Blevins,1 and Kara Noelle Shah1,4,5,*
1
Pediatric Advanced Wound and Skin Services, and Divisions of 2Pediatric General and Thoracic Surgery and
4
Dermatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
3
Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.
5
Departments of Pediatrics and Dermatology, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Significance: The increasing complexity of medical and surgical care provided


to pediatric patients has resulted in a population at significant risk for com-
plications such as pressure ulcers, nonhealing surgical wounds, and moisture-
associated skin damage. Wound care practices for neonatal and pediatric
patients, including the choice of specific dressings or other wound care prod-
ucts, are currently based on a combination of provider experience and pref-
erence and a small number of published clinical guidelines based on expert
Kara Noelle Shah, MD, PhD opinion; rigorous evidence-based clinical guidelines for wound management in
Submitted for publication May 17, 2013.
these populations is lacking.
Accepted in revised form September 20, 2013. Recent Advances: Advances in the understanding of the pathophysiology of
*Correspondence: Division of Pediatric Der- wound healing have contributed to an ever-increasing number of specialized
matology, Cincinnati Children’s Hospital, 3333
Burnet Ave., MLC 3004, Cincinnati, OH 45229
wound care products, most of which are predominantly marketed to adult
(e-mail: kara.shah@cchmc.org). patients and that have not been evaluated for safety and efficacy in the neo-
natal and pediatric populations. This review aims to discuss the available data
on the use of both more traditional wound care products and newer wound care
technologies in these populations, including medical-grade honey, nanocrys-
talline silver, and soft silicone-based adhesive technology.
Critical Issues: Evidence-based wound care practices and demonstration of the
safety, efficacy, and appropriate utilization of available wound care dressings
and products in the neonatal and pediatric populations should be established to
address specific concerns regarding wound management in these populations.
Future Directions: The creation and implementation of evidence-based guide-
lines for the treatment of common wounds in the neonatal and pediatric pop-
ulations is essential. In addition to an evaluation of currently marketed wound
care dressings and products used in the adult population, newer wound care
technologies should also be evaluated for use in neonates and children. In ad-
dition, further investigation of the specific pathophysiology of wound healing in
neonates and children is indicated to promote the development of wound care
dressings and products with specific applications in these populations.

SCOPE AND SIGNIFICANCE of the literature on the following spe-


Given the lack of consensus on the cific areas of focus: pressure ulcers,
optimal strategies for common wound surgical wounds, epidermal stripping,
care management issues in the neo- intravenous extravasation injuries,
natal and pediatric populations and moisture-associated skin damage
the large number of wound care prod- (MASD), and use of negative-pressure
ucts on the market today, it can be wound therapy (NPWT) is presented,
challenging to make informed deci- along with management recommen-
sions regarding wound care in these dations based on the clinical experi-
populations. A comprehensive review ence of the authors.

324 j ADVANCES IN WOUND CARE, VOLUME 3, NUMBER 4


Copyright ª 2014 by Mary Ann Liebert, Inc. DOI: 10.1089/wound.2013.0477
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 325

TRANSLATIONAL RELEVANCE lence of other forms of skin breakdown of 14.8%;


Application of continuing advances in the un- 66% of pressure ulcers were facility associated.4 A
derstanding of the pathophysiology of wound 1998 survey of 215 neonatal intensive care units
healing, in particular in neonates and children, reported that an average of 21% of extremely low
will hopefully result in the development of ad- birth weight neonates developed skin breakdown
vanced wound care products and technologies that in the first week of life.5
address the specific needs of these populations. A significant number of children will be dis-
charged from the hospital with a chronic wound, a
stoma, or a predisposition to impaired skin integ-
CLINICAL RELEVANCE
rity that will, by necessity, require some form of
Despite the lack of evidence-based clinical
home management. Among children receiving
guidelines for wound management in the neonatal home care, a study of 13 home care agencies indi-
and pediatric populations, clinical practice deci- cated that 17% of children had a wound; most were
sions can be aided by a thoughtful consideration of
treated with hydrogen peroxide, household soap, or
the published literature and of expert opinion. povidone-iodine and either left uncovered or cov-
Such information can also guide future clinical ered with dry or saline-soaked gauze.6 These
investigations into the safety and efficacy of the use
studies further highlight the lack of clinical
of these products in children as part of a compre- knowledge and consensus on the most appropriate
hensive initiative to develop evidence-based clini- standards for wound management in children.
cal guidelines for the treatment of acute and
chronic wounds in the neonatal and pediatric Overview of wound care in pediatrics
populations. Fundamentals of wound care in the neonatal
and pediatric population are similar to those ap-
DISCUSSION OF FINDINGS plicable to adults and include eliminating any
AND RELEVANT LITERATURE identifiable contributing factors when possible,
Prevalence of wounds in pediatrics cleansing of the wound, debridement of devitalized
Despite rapid advances in medical and nursing tissue where appropriate, providing a moist wound
care for pediatric and neonatal patients and the environment to promote wound healing, identify-
increasingly complex level of care provided to these ing and treating associated infection, and protect-
patients, there has been limited formal assessment ing the intact skin surrounding the wound from
of the prevalence, type, and management of maceration and skin breakdown.7,8 Optimizing
wounds in this population. The hospitalized neo- patient nutritional status is also a very important
natal and pediatric population is at significant risk factor.9 As compared to adults, however, there are
for the development of acute and/or chronic wounds important age-related and neurodevelopmental
and other skin-related injuries.1 A series of three considerations that impact wound care in the neo-
hospital-acquired skin injury (HASI) prevalence natal and pediatric populations (Table 1).10
surveys performed over 2010–2011 at a university- Specific concerns in the neonatal population, in
affiliated tertiary-care children’s hospital revealed particular in premature neonates, include an im-
that pressure ulcers, both medical device-related paired epidermal barrier, immaturity of the de-
and immobility-related, was the most common type veloping immune system with increased risk for
of HASI, with point prevalence rates of 1.7–3.5%; infection and impaired thermoregulation.8 By 34
diaper dermatitis/irritant-associated dermatitis weeks of gestation or usually within 2–3 weeks of
was the next most common cause of HASI.2 In life in preterm infants, the epidermal barrier is
2005, a one-day skin integrity audit performed on usually functionally mature, although skin fra-
all inpatients hospitalized at another university- gility and susceptibility to irritants and increased
affiliated tertiary-care children’s hospital revealed risk for percutaneous absorption of topical agents
that 43% of patients had a wound and/or surgical persists. Prior studies have documented disparities
incision, 16% of patients with urine and/or stool in clinical practice with regards to basic skin
incontinence developed diaper dermatitis, and 6% care and wound management in neonatal inten-
of patients were felt to be at risk for the develop- sive care units.11,12 In 2001, the Association of
ment of pressure ulcers as based on Braden Q score Women’s Health, Obstetric, and Neonatal Nurses
assessment.3 A 2003 multisite study examining the and the National Association of Neonatal Nurses
prevalence of pressure ulcers and skin breakdown published evidence-based clinical practice guide-
in the pediatric inpatient population revealed a lines for general neonatal skin care.13 In infants
pressure ulcer prevalence of 4.0% and the preva- and children, wound care recommendations must
326 KING ET AL.

Table 1. Wound care considerations in neonates, infants,


and children

Premature neonate
Impaired epidermal barrier
 Increased transepidermal water loss and electrolyte imbalance
 Skin fragility and increased risk of epidermal stripping
Increased percutaneous absorption of topical agents due to increased body
surface area to weight ratio (e.g., alcohols, povidone-iodine)
Susceptibility to irritants
Impaired thermoregulation
Immature immune system
Term neonate
Skin fragility
Increased percutaneous absorption of topical agents due to increased body
surface area to weight ratio
Susceptibility to irritants
Impaired thermoregulation
Immature immune system
Infant
Increased percutaneous absorption of topical agents due to increased body Figure 1. Optimal product choice for local wound care based on depth of
surface area to weight ratio injury and amount of exudate.
May attempt to remove dressings
May contaminate wound and dressings, including the diaper area
Need to place dressings securely due to crawling, running, and playing
Fear, anxiety, and pain may complicate wound care and dressing changes
that may interfere with wound healing. Manage-
Child
ment of the wound is a dynamic process, and the
May attempt to remove dressings astute clinician should frequently reassess the
May contaminate wound and dressings wound with regard to wound bed factors, including
Need to place dressings securely due to running and playing the depth of injury and amount of exudate, and
Fear, anxiety, and pain may complicate wound care and dressing changes,
in particular with removal of adhesive dressings (‘‘tape phobia’’)
with regard to the overall patient condition and
Need for developmentally appropriate preparation for wound care and modify the use of wound care dressings and other
dressing changes, including use of child life specialists and caregivers products as needed (Fig. 2).
to provide psychological support and distraction Wound care products and dressings have
Neurodevelopmental delays may further complicate wound care
evolved dramatically from the use of simple wet or
dry gauze to highly specialized skin care products
also include neurodevelopmental and behavioral (Table 2). Although the use of wet-to-dry gauze
considerations. dressings is still a common practice in wound care,
Fortunately, in the majority of otherwise heal- the use of wet-to-dry gauze has been shown to
thy children, wound healing is brisk, uncompli- cause nonselective mechanical debridement of the
cated, and requires minimal specialized attention.
Chronically ill children, however, in particular
those with limited mobility, poor nutritional sta-
tus, immune compromise, neurodevelopmental
delays, and/or frequent hospitalization are predis-
posed to poor wound healing and iatrogenic skin
injury.
Wound healing is a complex, dynamic process
that involves four basic phases: coagulation and
hemostasis; inflammation; proliferation and re-
pair; and wound maturation and remodeling.14 As
such, the use of specific wound care products by
necessity may need to be adjusted during the
wound healing process (Fig. 1). Optimal product
choice is dependent on several factors: the type of
wound present; the overall condition of the patient,
including any relevant comorbidities; and the
condition of the wound bed, including the presence
Figure 2. Considerations in dressing and product choice based on the
of infection, excessive granulation tissue, or the
different phases of wound healing.
presence of devitalized tissue (slough or eschar)
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 327

wound that results in injury to normal tissue, re- Wound management issues in pediatrics
sults in desiccation of the wound bed, and is asso- Pressure ulcers. Pressure ulcers are common in
ciated with periwound maceration and increased hospitalized neonates, infants, and children, with
pain during dressing changes; in addition, use of estimates of point prevalence ranging from 10%
wet-to-dry gauze dressings has been associated to 35%, and they are most common in patients
with increased cost and labor due to need for more requiring management in an intensive care
frequent dressing changes and with an increased unit.18,22,23 The most common sites for the devel-
risk for infection.15 Alternative, less painful op- opment of pressure ulcers in neonates and children
tions for selective debridement include use of oc- related to immobility are the sacrum/coccyx (most
clusive dressings to promote autolysis, use of common site in children), occiput (most common site
hydrogels, and enzymatic debridement. Use of ap- in infants), and heels.24 More than 50% of pressure
propriate wound care products and dressings help ulcers in hospitalized children are related to pres-
to maintain an optimal wound healing environ- sure from devices and equipment, including blood
ment by maintaining adequate moisture, humid- pressure cuffs; tracheostomy cannulas, connectors,
ity, pH, and temperature, by minimizing pain, and and tubing; oxygen delivery devices such as nasal
by preventing damage to the skin surrounding the prongs, noninvasive positive pressure ventilation
wound such as epidermal stripping and maceration interfaces, and continuous positive airway pressure
as well as to address issues such as delayed wound masks; and cutaneous oximetry probes.25 In chil-
healing due to complications such as bacterial in- dren, pressure ulcers related to medical devices are
fection, necrotic devitalized tissue, exudate, and seen most frequently on the head and neck in as-
slough. Use of specialized wound care dressings sociation with the presence of a tracheostomy or
may also require less frequent dressing changes. noninvasive positive pressure ventilation interface,
However, overall data on the use of these prod- on the torso in association with placement of elec-
ucts even in adults are extremely limited, with a trocardiography leads, and on the digits in associa-
recent assessment of published randomized con- tion with use of pulse oximeter probes.2,3,26
trolled trials, meta-analyses, and cost-effective- The Braden Q Scale and Modified Braden Q Scale
ness studies providing only weak levels of clinical were developed to allow for standardized assess-
efficacy.16 ment of pressure ulcer risk in pediatric patients.
There are currently only a limited number of These scales are based on assessment of mobil-
published clinical guidelines for the evaluation and ity, activity, sensory perception, moisture, friction/
management of wounds in the neonatal and pedi- shear, nutrition, and tissue perfusion/oxygenation
atric populations.2,13,17–21 None of these have un- (Fig. 3B) and help to identify pediatric patients
dergone the rigorous assessment required for the requiring care in a pediatric intensive care unit
generation of evidence-based guidelines. As such, who are at risk for the development of pressure
wound care practices and selection of wound care ulcers.27,28 Prevention of pressure ulcer development
products tend to reflect provider experience and is a major nursing initiative, and is dependent on
preference.1 Given these constraints, the authors comprehensive and frequent patient assessment
have utilized a combination of literature review and pressure distribution in at-risk areas through
and personal experience on which to base a the use of interventions such as appropriate pad-
thoughtful discussion of the use of dressings and ding of bony prominences and devices that come in
other wound care products in the neonatal and contact with the skin; use of age-appropriate spe-
pediatric populations with an emphasis on the cialty mattress such as an alternating pressure
management of pressure ulcers, epidermal strip- mattress, low-air loss, or foam or gel overlay; fre-
ping, surgical wounds, MASD, and intravenous quent repositioning; and frequent assessment and
extravasation injury and on the use of NPWT. rotation, when possible, of medical devices.1,10,29
Basic information on types of dressings, examples Unfortunately, despite use of appropriate preven-
of specific products often used in neonates and tative measures, pressure ulcers may still occur.
children, indications for use, and special consider- The most commonly used dressings in the man-
ations/cautions with use is presented in Table 2. A agement of pressure ulcers in the pediatric popu-
discussion of other wound care strategies, includ- lation include hydrocolloids, hydrogels (available
ing use of bioengineered skin substitutes, and of as amorphous gel and sheets), polyurethane foams,
wound care for specialized population such as pa- and transparent films.30,31 In addition, NPWT is
tients with epidermolysis bullosa, toxic epidermal also used in the management of Stage III and Stage
necrolysis, cutaneous graft versus host disease, or IV pressure ulcers. Medical device-related pres-
burns, is beyond the scope of this article. sure ulcers is a challenge in neonates and children
328 KING ET AL.

Table 2. Wound care products commonly used in neonates, infants, and children

Dressing Class Adhesion Indications Function Precautions Examples

Transparent May contain Skin tears Prevents wound Semipermanent; not Tegaderm
polyurethane film adhesive Superficial wounds with contamination intended for frequent Opsite
little to no exudate Provides moist wound dressing changes
Secondary dressing healing May result in epidermal
Secure devices to skin Promotes autolytic stripping (if adhesive
debridement present)
Nonabsorptive
Contact layer Some contain soft- Superficial tears Prevents wound Requires secondary Mepitel
silicone adhesive Superficial wounds with contamination dressing Mepital-One
little to no exudate Provides moist wound N-TERFACE
First- and second-degree healing Restore Contact
burns Allows transfer of Restore Contact Silver
Minimal to moderate exudate into Versatel
exudative wounds absorbant dressing Adaptic
Pressure ulcers Nonabsorptive Xeroform
Partial and full-thickness Conformant Wound Veil
wounds
Hydrocolloid (gelatin, May contain Minimal to moderate Prevents wound Caution in infected Duoderm
pectin, and/or adhesive exudative wounds contamination wounds Tegasorb
carboxymethyl Pressure ulcers Promotes autolytic May cause maceration Medihoney
cellulose) Partial and full-thickness debridement of periwound
wounds Minimal absorption May result in epidermal
Promotes autolytic Ease of use stripping (if adhesive
debridement present)
Pressure redistribution
Polyurethane foam and May contain Moderate to heavy Ease of removal (only if Not for use in dry Polymema
composite adhesive exudative wounds nonadherent or wounds Allevyn
Partial and full-thickness containing soft Requires a secondary Lyofoam
wounds silicone adhesive) dressing (unless Mepilex
Peristomal Ease of use compositie) Mepilex-Ag
Pressure redistribution Moderate absorption Hydrosorb
Infected woundsb Pressure redistribution
Comfortable
Hydrogel Nonadherent Minimal exudate or dry Pressure redistribution May over-hydrate Sheet:
wounds Reduce pain wound  Vigilon
Partial and full-thickness Promotes autolytic May macerate  Elastogel
wounds debridement periwound; consider Amorphous:
Burns Promotes applying skin sealant  Solosite
epithelialization first as protection  Intrasite
Adds moisture Requires secondary  Normlgel
Minimal to moderate dressing  Hypergel
absorption  Carrasyn wound gel
Fills dead space
Ease of removal
Hydrofiber (sodium None Moderate to heavy Promotes autolytic Requires secondary Aquacel
carboxymethyl exudative wounds debridement dressing Aquacel-Ag
cellulose) Partial and full-thickness Moderate to marked
wounds absorption
Wound dehiscence Ease of removal
Infected woundsb
Wounds requiring
packing
Alginate None Moderate to heavy Promotes autolytic Requires secondary Kaltostat
exudative wounds debridement dressing Medihoney
Partial and full-thickness Moderate to marked Maxorb extra
wounds absorption Maxorb extra-Ag
Wound dehiscence Ease of removal
Infected woundsb
Wounds requiring
packing

(continued )
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 329

Table 2. (Continued)

Dressing Class Adhesion Indications Function Precautions Examples

Barrier None Diaper dermatitis Protects against May be difficult to Stomahesive wafer
Peristomal moisture-associated assess wound with Stomahesive powder
skin damage opaque preparations Coloplast wafer
Protects against Residual cream or Sensicare cream
epidermal stripping ointment should not Criticaid ointment
Protects against be removed prior to White petrolatum
irritation from reapplication Zinc oxide ointment
adhesives Cavilon No-Sting barrier
Marathon
a
Contains starch co-polymer, glycerol, and surfactant and approved for use in full- and partial-thickness wounds, ulcers, skin tears, surgical wounds, and
first- and second-degree burns.
b
Dressings containing silver.

and strategies to prevent these injuries include The use of dressings with soft silicone adhesive
protection of underlying skin, frequent assess- technology has also been associated with signifi-
ments of skin located under the device, and fre- cantly reduced pain during dressing changes.34,35
quent rotation of devices, if possible. Prevention of Choice of an adhesive dressing is dependent on
tracheostomy-related pressure ulcers is aided by several factors, including the need to manage
frequent clinical assessment of the tracheostomy wound exudate, the need to minimize skin trauma
site and by the use of a moisture-reducing and during removal, the need for the dressing to remain
pressure-reducing device interface.20 Simple use of in place in areas of high tension, sustained adhe-
a thin hydrocolloid or thin polyurethane foam un- sion for the duration of the wear time.36 Use of a
der the tracheostomy cannula, securement ties, skin barrier product prior to the application of the
and ventilator connector may also be effective.32 In dressing may also minimize epidermal stripping;
the authors’ experience, use of a polyurethane however, use of a skin protectant under a product
foam dressing with a gentle adhesive such as soft with a soft silicone adhesive may interfere with
silicone is preferred to use of a hydrocolloid dress- dressing adherence. Once epidermal stripping has
ing due to the increased risk of epidermal stripping occurred, management strategies to promote re-
and skin irritation from the adhesive in the hy- epithelialization may include application of barrier
drocolloid dressings and use of a dressing with ointment or cyanoacrylate liquid or application of a
silver is helpful for colonized tracheostomy transparent film dressing.37
wounds. Amorphous hydrogels and silver impreg-
nated dressings have been used in the neonates to Surgical wounds. Surgical wounds are common
treat several types of skin injury, including pres- in the pediatric population, yet there are no clear
sure ulcers.21 guidelines for routine postoperative management
(Fig. 3D). Complications include wound dehiscence
Epidermal stripping. Epidermal stripping is a and infection, which are predictors of poor wound
common form iatrogenic skin injury in neonates healing and other complications. Postoperative
and in any pediatric patient with compromised wound complications are particularly common af-
skin integrity, despite the use of an adhesive re- ter tracheostomy placement, occurring in 29% of
mover prior to removal of adhesive dressings (Fig. patients in one published series.38 Amorphous hy-
3C). In addition, adhesive removal is painful and drogels have been used in the neonatal intensive
often a source of fear and anxiety in the hospital- care unit to treat several types of surgical wounds
ized child. An evaluation of several common skin in the neonatal population, including tracheostomy
dressings, including one using soft silicone adhe- sites.21 In the authors’ experience, use of a hydro-
sive technology, demonstrated the development of gel is also helpful in maintaining a moist wound
epidermal stripping with use of all dressings except environment in neonates with congenital anoma-
the one using a soft silicone adhesive; the use of the lies with exposed mucosa such as cloacal or bladder
dressing with soft silicone adhesive also minimized exstrophy.
transepidermal water loss, a measure of epidermal Surgical site infections occur in 2.5–6.7% of
barrier function.33 In the authors’ experience, use postoperative wounds and are more common in
of products with soft silicone adhesive technology is contaminated and dirty/infected surgical sites.39–41
typically better tolerated by neonates and children Preventing critical colonization and frank infection
with skin fragility or impaired epidermal barrier. of wounds is an important component of postoper-
330 KING ET AL.

Figure 3. Normal skin with intact epidermis, dermis, and subcutaneous tissue (A). Conditions leading to pressure ulcer development include increased
pressure at the surface of the skin in conjunction with shear forces (B). Injury resulting from epidermal stripping (C), surgical wounding (D), moisture-
associated skin damage (E), and intravenous extravasation injury (F). To see this illustration in color, the reader is referred to the web version of this article at
www.liebertpub.com/wound

ative wound care; however, it has been suggested of dressings and skin care incorporating use of
that routine use of a wound dressing after clean honey in neonates have also been published.43 In
surgery has no impact on the development of post- the authors’ experience, some patients may report
surgical wound infections in children.42 In addition stinging with use of medical grade honey products,
to the use of a variety of topical antimicrobial but overall they appear well tolerated and have
agents, specialized dressings with bacteriostatic or been successfully used in the treatment of extrav-
bactericidal properties are also available for the asation injury in neonates and in the management
treatment of colonized and/or infected wounds, in- of pressure ulcers in neonates and children of all
cluding surgical wounds. The most commonly used ages.
antimicrobial agents incorporated into wound Use of wound dressings containing silver as an
dressings are honey and silver ions. antibacterial agent in the management of critically
Honey has been used for centuries in many parts colonized wounds and in the management of burns
of the world for wound management and has sev- has gained popularity in adults; however, use in
eral antimicrobial properties, including high os- children has not received rigorous evaluation.
motic pressure, low pH, high sugar content, and There are several different technologies that in-
production of hydrogen peroxide.43 Several studies volve the incorporation of silver into wound dress-
have documented the efficacy of medical grade ings, including nanocrystalline silver and ionic
honey in augmenting wound healing and addres- silver. Silver ions exert anti-inflammatory and
sing bacterial colonization of wounds in the pedi- antibacterial effects; although nanocrystalline
atric population, in particular in oncology technology appears to provide the lowest risk of
patients.44,45 Although limited, reports on the use toxicity and the highest level of sustained silver
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 331

release to the wound, concerns exist regarding their Skin issues related to MASD are common in
safety.46,47 Use in children must take into consid- children with gastrostomy tubes and include gran-
eration concerns for silver toxicity as elevated se- ulation tissue formation, infection, and skin irrita-
rum silver levels have been documented in children tion as a result of leakage.54,55 Use of a hydrocolloid
with burns treated with silver-containing dress- or foam dressing to protect the skin around the
ings.48 Due to these concerns, the authors advocate gastrostomy site may be helpful in minimizing ir-
for judicious use of silver-containing wound care ritation from leakage, although in the authors’ ex-
products in children and for limiting their use to no perience use of a hydrofiber dressing around the
more than two consecutive weeks when possible. gastrostomy is more helpful when there is a signif-
There are several reports in the literature detailing icant amount of drainage due to the limited ab-
use of silver-impregnated dressings in children, sorptive capacity of hydrocolloid dressings. In the
predominantly in burn care.49–51 experience of one of the authors, use of a hydrofiber
Wound dehiscence is a significant risk factor for dressing around the gastrostomy can also help to
postsurgical morbidity and mortality. Risk factors prevent the formation of hypergranulation tissue. A
for wound dehiscence after laparotomy in children barrier ointment such as petrolatum or zinc oxide or
include age less than 1 year, presence of wound a skin-protection powder may be applied to irritated
infection, median incision, and emergency sur- or eroded skin as needed and are also helpful in the
gery.52 A number of different approaches to the management of ileostomy and colostomy site der-
management of wound dehiscence may be consid- matitis.56 The authors find that the application of
ered depending on the size and location of the Stomahesive Protective Powder combined with a
wound and on the presence of infection. Appro- skin barrier product such as 3M Cavilon No Sting
priate wound assessment includes the following: Skin Barrier or Coloplast Brave Skin Barrier Wipe
the depth of the wound; the condition of the wound (‘‘crusting technique’’) followed by application of a
bed including the presence of granulation tissue, barrier ointment is a very effective strategy for the
slough, and/or eschar; the presence of exposed su- management of MASD. Skin protection can also be
tures, hardware, supporting structure (muscle, achieved with use of a cyanoacrylate topical liquid.
bone tendon, and muscle/fascia), or internal or- When dry, these agents create a flexible barrier
gans; the amount and type of drainage; the pres- against moisture, friction, and irritants. In the ex-
ence of odor; the condition of the wound margins; perience of one the authors, they are particularly
the presence of associated pain; and the condi- useful for protection against highly caustic effluent
tion of the periwound skin. Commonly used dress- from high output ostomies, incontinence-associated
ings for the management of wound dehiscence dermatitis in patients with short bowel syndrome,
include alginates, hydrofibers, hydrogels, hydro- and for protection around various feeding and sur-
colloids, and foams, depending on the character- gical tubes such as biliary drains. They are not in-
istics of the wound. In selected patients, use of dicated for use in deep, open wounds; chronic or
NPWT may be considered in the management of nonhealing wounds; second- or third-degree burns;
chronic and/or otherwise complicated surgical or infected wounds.
wounds.
Intravenous extravasation injury. Extravasation
Moisture-associated skin damage. MASD re- injury associated with use of intravenous catheters
sults from prolonged skin exposure to factors such is common in hospitalized children, in particular in
as urine, stool, saliva, mucus, and wound exudate, neonates, and tissue damage and necrosis can re-
which in combination with other factors such as sult in significant scarring and long-term compli-
friction, microorganisms, and chemical irritation, cations (Fig. 3F). For significant extravasation
results in skin inflammation (Fig. 3E).53 Diaper injury in neonates that results in moderate to se-
dermatitis is the most common type of MASD ob- vere swelling, blanching, and pain at the site with
served in the pediatric inpatient population with a skin that is cool to the touch, with or without de-
point prevalence of 24% in one study; a compre- creased or absent distal pulses and evidence of
hensive literature review combined with expert tissue necrosis, the use of an aqueous gel followed
opinion and benchmarking with several large pe- by the application of a hydrofiber sheet covered by
diatric hospitals concluded that the available evi- a hydrocolloid dressing has been suggested as a
dence supports the use of superabsorbent diapers reasonable approach to management.57 Use of a
with frequent diaper changes and routine use of hydrogel dressing or product alone has also been
skin protectants containing petrolatum and/or zinc reported to be effective in the management of ex-
oxide in the perineal area.17 travasation injury.21,58
332 KING ET AL.

Negative-pressure wound therapy.


TAKE-HOME MESSAGES
NPWT, also known as vacuum-assisted
 Although general principles of wound healing are similar in children and
closure, has been shown to facilitate adults, there are limited clinical guidelines to direct the choice of specific
wound healing for a variety of acute and wound care products in the management of wounds in children.
chronic wounds in adults. NPWT reduces
 Developmental and behavioral considerations should be taken into ac-
tissue edema, increases tissue perfusion,
count when choosing wound management strategies in neonates, in-
removes exudate, and facilitates granu-
fants, and children.
lation tissue formation. Several retro-
spective case series provide evidence that  Epidermal stripping of neonatal skin in particular and of compromised
use of NPWT in neonates and children skin in pediatric patients of any age is a common form iatrogenic skin
injury that can be minimized with the use of dressings with soft silicone-
can augment wound healing in a variety
based adhesives.
of acute and chronic wounds, including
infected wounds, those with exposed or-  The use of medical-grade honey appears to be safe and well tolerated
thopedic hardware, and surgical wound for use in children.
dehiscence, with successful use reported  The use of silver-based technology in wound dressings for use in children
in 92–100% of patients.19,59–63 Reported to provide antimicrobial properties requires additional evaluation due to
complications, including enteric fistula concerns regarding silver toxicity, although the use of newer nanocrys-
formation, bleeding, pain, and periwound talline silver products appears promising.
skin breakdown, were uncommon and in  Wound care in neonates, infants, and children should also include ap-
the case of fistula formation, related at propriate neurodevelopmental assessment and modification of the
least in part to the patients’ underlying wound care regimen to ensure minimal pain and anxiety and to facilitate
disease process. In addition to facilitating wound healing.
wound healing, benefits of NPWT in-
cluded decreased frequency of dressing
changes, reduced need for use of pain medication, atric populations, the available technologies for
and decreased length of hospital stay. advanced wound care continue to evolve; thus, ad-
The safety and efficacy of these devices in neo- ditional wound care products with potential pedi-
nates, infants, and children, however, has not been atric and/or neonatal applications will hopefully
established and there are no devices that are ap- emerge in the future. In addition, further investi-
proved by the U.S. Food and Drug Administration gation of the specific pathophysiology of wound
for use in these populations; serious safety events, healing in neonates and children is indicated to
including injury and death related to bleeding and promote the development of wound care dressings
infection secondary to retained foam dressing and products with specific applications in these
particles, have been reported in adults treated with populations.
NPWT. Guidelines for the use of NPWT in neona-
tes, infants, and children have been proposed and
include age- and wound-specific recommendations CONCLUSIONS
for negative pressure settings and choice of foam The lack of evidence-based clinical guidelines
19
dressing. In the experience of several of the au- for the prevention and management of common
thors, negative pressure settings that correlate to skin and wound issues in the neonatal and pedi-
- 25 mmHg above the mean arterial blood pressure atric population is an obstacle to the provision of
of the patient in the neonate, infant, and toddler appropriate and accountable care. The develop-
population are initially utilized and adjusted as ment of evidence-based practice guidelines that
needed based on comorbidities, perfusion status, address these concerns and incorporate the ra-
wound location, and pain tolerance. Providers tional choice of specialized wound care dressings
should remember that neonates and infants in and products should be a priority for wound care
particular are at risk for fluid loss and dehydration specialists with pediatric and neonatal expertise
during treatment with NPWT. with a goal of promoting standardization of clini-
cal practices.

FUTURE CONSIDERATIONS
In addition to the promotion of an initiative to ACKNOWLEDGMENTS
develop clinical trials to address the safety and ef- AND FUNDING SOURCES
ficacy of the use of currently marketed wound care The authors have not received funding for this
dressings and products in the neonatal and pedi- work.
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 333

AUTHOR DISCLOSURE AND GHOSTWRITING Philadelphia. She has an interest in pediatric


No competing financial interests exist. The con- surgical wounds, pressure ulcers, incontinence-
tent of this article was expressly written by the associated dermatitis, and complex congenital
authors listed. No ghostwriters were used to write anomalies requiring ostomies. Anne Blevins,
this article. BSN, RN, WCC, CWOCN, is a Certified Wound
Ostomy Continence Nurse with the Pediatric
Advanced Wound and Skin Services at Cincin-
ABOUT THE AUTHORS nati Children’s Hospital Medical Center. She
Alice King, MD, is a General Surgery Re- has an interest in developing a standardized
sident in the Department of Surgery at the nursing guideline for Pediatric Wound Care and
University of Cincinnati College of Medicine. management of moisture-associated skin dam-
She is completing a 2-year postdoctoral research age. Kara N. Shah, MD, PhD, is the Director of
fellowship as the Clinical and Translational Pe- the Division of Dermatology and the Medical
diatric Wound Healing and Research Fellow at Director of the Pediatric Advanced Wound and
the Cincinnati Children’s Hospital Medical Skin Services at Cincinnati Children’s Hospital
Center. Judith J. Stellar, MSN, CRNP, PNP- Medical Center. She has an interest in the di-
BC, CWOCN, is a Certified Pediatric Nurse agnosis and management of acute and chronic
Practitioner and Certified Wound Ostomy Con- disorders of the skin characterized by impaired
tinence Nurse at The Children’s Hospital of skin integrity and/or impaired wound healing.

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